NEW YORK STATE DEPARTMENT OF HEALTH 08/06 ... - eMedNY

NEW YORK STATE DEPARTMENT OF HEALTH 02/28/2014 PAGE: 247LIST OF MEDICAID REIMBURSABLE DRUGSRX TYPE: 01 PRICING ERRORS ARE NOT REIMBURSABLE PRICES EFFECTIVE 02/28/2014LTM BASISIND NDC CODE MRA COST COST ALTERNATE FORMULARY DESCRIPTION PA CD LABELER OF MRA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 60505-0192-01 0.04104 METFORMIN HCL 1,000 MG TABLET 0 APOTEX CORP EAGEN 60505-0192-08 0.04104 METFORMIN HCL 1,000 MG TABLET 0 APOTEX CORP EAGEN 61442-0363-01 0.04104 METFORMIN HCL 1,000 MG TABLET 0 CARLSBAD TECH EAGEN 61442-0363-05 0.04104 METFORMIN HCL 1,000 MG TABLET 0 CARLSBAD TECH EAGEN 65162-0177-50 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0220-10 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0220-11 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AMNEAL PHARMACE EAGEN 65162-0220-50 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AMNEAL PHARMACE EAGEN 65862-0010-01 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0010-05 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AUROBINDO PHARM EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 65862-0010-46 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AUROBINDO PHARM EAGEN 65862-0010-99 0.04104 METFORMIN HCL 1,000 MG TABLET 0 AUROBINDO PHARM EAGEN 67877-0221-01 0.04104 METFORMIN HCL 1,000 MG TABLET 0 ASCEND LABORATO EAGEN 68382-0030-01 0.04104 METFORMIN HCL 1,000 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0030-05 0.04104 METFORMIN HCL 1,000 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68382-0030-10 0.04104 METFORMIN HCL 1,000 MG TABLET 0 ZYDUS PHARMACEU EAGEN 68462-0161-01 0.04104 METFORMIN HCL 1,000 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0161-05 0.04104 METFORMIN HCL 1,000 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0161-10 0.04104 METFORMIN HCL 1,000 MG TABLET 0 GLENMARK PHARMA EAGEN 68462-0161-18 0.04104 METFORMIN HCL 1,000 MG TABLET 0 GLENMARK PHARMA EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 68462-0161-90 0.04104 METFORMIN HCL 1,000 MG TABLET 0 GLENMARK PHARMA EAGEN 68645-0300-59 0.04104 METFORMIN HCL 1,000 MG TABLET 0 LEGACY PHARMACE EAGEN 00093-1048-01 0.02633 METFORMIN HCL 500 MG TABLET 0 TEVA USA EAGEN 00093-1048-10 0.02633 METFORMIN HCL 500 MG TABLET 0 TEVA USA EAGEN 00093-1048-98 0.02633 METFORMIN HCL 500 MG TABLET 0 TEVA USA EAGEN 00378-7185-05 0.02633 METFORMIN HCL 500 MG TABLET 0 MYLAN EAGEN 00603-4467-21 0.02633 METFORMIN HCL 500 MG TABLET 0 QUALITEST EAGEN 00603-4467-28 0.02633 METFORMIN HCL 500 MG TABLET 0 QUALITEST EAGEN 00603-4467-32 0.02633 METFORMIN HCL 500 MG TABLET 0 QUALITEST EAGEN 00781-5050-01 0.02633 METFORMIN HCL 500 MG TABLET 0 SANDOZ EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00781-5050-05 0.02633 METFORMIN HCL 500 MG TABLET 0 SANDOZ EAGEN 00781-5050-10 0.02633 METFORMIN HCL 500 MG TABLET 0 SANDOZ EAGEN 00781-5050-61 0.02633 METFORMIN HCL 500 MG TABLET 0 SANDOZ EAGEN 00904-5849-14 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5849-18 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5849-40 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5849-53 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5849-54 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5849-80 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-5849-89 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EA--- ------------- ------------ -------------- -------------------------------------------------- ----- ------------------ ----------GEN 00904-5849-93 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6326-61 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-14 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-18 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EAGEN 00904-6343-40 0.02633 METFORMIN HCL 500 MG TABLET 0 MAJOR PHARMACEU EA** PRIOR APPROVAL CODES:PA code "0" = PA not required; PA code "N" = PA requiredPA code "G" = PA required for Non Preferred drugs OR drugs not meeting clinical criteria (FQD, STEP) OR drugs inClinical Drug Review Program, the Brand Less than Generic Program or the Mandatory Generic Program*** OTC, SUPPLY AND COMPOUND PRODUCTS LISTING AT BACK OF REPORT